中国实用外科杂志

中国实用外科杂志

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复杂肝内胆管结石60例诊治分析

李淳洋，倪其泓，王    坚   

  1. 上海交通大学医学院附属仁济医院胆胰外科，上海200127
  • 出版日期:2016-03-01 发布日期:2016-03-01

  • Online:2016-03-01 Published:2016-03-01

摘要：

目的    探讨复杂肝内胆管结石合理的诊断与治疗方式。方法    回顾性分析上海交通大学医学院附属仁济医院2011年1月至2015年10月手术治疗60例复杂肝内胆管结石的影像学资料、手术方式、并发症与疗效。结果    根据肝胆管结石病分型，Ⅰ型（区域型）44例，Ⅱ型（弥漫型）16例，E型（附加型，合并肝外胆管结石）28例。肝功能Child分级59例为Child A级，1例为Child B级。术前单用CT诊断灵敏度为86.7%，单用MRI+磁共振胰胆管造影（MRCP）诊断灵敏度93.9%。术前用CT+MRI诊断灵敏度为97.2%。60例均行肝叶或肝段切除术，其中12例合并高位胆管狭窄行胆肠吻合。手术并发症发生率25%。无术后肝功能衰竭和围手术期死亡病例。术毕联合应用B超和胆道镜检查，残石率为0（0/25），明显低于单用胆道镜取石探查组的20%（7/35）。55例获得3个月至5年的随访，随访率91.6%，其中优良率达96.2%，残石率11.7%，复发率9.61%。结论    联合B超、上腹部CT和MRI+MRCP能提高肝内胆管结石的检出率，术中联合运用胆道镜与术中B超能降低残石率，解剖性肝切除能降低残石率与结石复发率。

关键词: 复杂肝内胆管结石, 解剖性肝切除, 残石, 胆道镜, 术中超声

Abstract:

Diagnosis and treatment of complicated intrahepatic bile duct stone：An efficacy analysis of 60 cases        LI Chun-yang, NI Qi-hong, WANG Jian. Department of Hepatic and Biliary-Pancreatic Surgery, Renji Hospital of Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
Corresponding author: WANG Jian, E-mail: dr_wangjian@126.com
Abstract    Objective    To investigate the reasonable approach of diagnosis and treatment to complicated intrahepatic bile duct stone  Methods    The radiological diagnosis，surgical approach，complication and clinical efficacy of 60 cases of complicated intrahepatic bile duct stone performed surgical treatment from January 2011 to October 2015 in Renji Hospital of Shanghai Jiao Tong University School of Medicine were analyzed retrospectively. Results    According to the classification of hepatolithiasis，44 cases were type I (regional type)，16 cases were type II (diffused type)，and 28 cases were type E (additional type，combined with extrahepatic bile duct stone). A total of 59 cases were Child A grade and 1 case was Child B grade. The sensitivity of diagnosis of single-CT，single-MRI+MRCP，and CT combined with MRI were 86.7%，93.9% and 97.2% respectively. All the 60 cases underwent anatomical liver resection，and 12 cases with high-position bile duct stricture underwent cholangioenterostomy. The complication rate was 25% with no liver failure or perioperative death. The residual stone rate in patients using intraoperative ultrasound combined with choledochoscope was 0 (0/25)，which was significantly lower than that in patients using choledochoscope only (20%，7/35). A total of 55 cases had follow-up from three months to five years. The follow-up rate was 91.6%; high life quality rate was 96.2%; residual stone rate was 11.7%，and recurrence rate was 9.61%. Conclusion    Using ultrasound combined with upper abdominal CT and MRI+MRCP can increase the detection rate of intrahepatic bile duct stone. Using choledochoscope combined with intraoperative ultrasound can decrease the residual stone rate. Anatomical liver resection can decrease the residual stone rate and recurrence rate.

Key words: complicated intrahepatic bile duct stone, anatomical liver resection, residual stone, choledochoscope, intraoperative ultrasound